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Acute Renal Failure
Rapid onset: Hours to Days
Potentially Reversible
S/sx: 4 phases
Initiating, Oliguric, Diuretic, Recovery
Chronic Renal Failure
Slow onset: Months to years
Every body system affected
S/Sx: Uremia, weakness, n/v, lethargy, confusion
Prerenal causes of ARF
Hypovolemia, Decreased CO, Decreased PVR, Vascular obstruction, CHF, Cardiogenic shock, MI, dehydration, Dysrhythmias, Burns
External factors decrease glomerular perfusion/filtration
Kidneys respond with RAAS to increase BP
Decreases clearance of wastes-azotemia (uremic fetor/frost)
Prerenal can cause intrarenal if prolonged  (60-70% of intrarenal cases)
Intrarenal causes of ARF
Direct damage to parenchyma 
Prolonged ischemia, nephrotoxins, hemoglobin/myoglobin, acute glomerulonephritis, lupus
Acute Tubular Necrosis (ATN)
Ischemic & Nephrotoxic ATN (90% of intrarenal ARF) 
Postrenal causes of ARF
Mechanical obstruction of urinary outflow
BPH, Prostate CA, calculi (stones), trauma, extrarenal tumors
Azotemia is reversed if obstruction is relieved before damage occurs
Functions of the kidney
Regulates blood ionic composition: excretion/reabsorption
Regulates blood pH: excretes hydrogen/ conserves bicarb
Regulates blood volume: conserving and eliminating water in urine-RAAS
Regulates BP through RAAS
Maintains blood osmolality: regulates water and solute loss separately
Produces hormones: Calcitriol (Vit D) and EPO
Regulates blood glucose: Use glutamine (amino acid) in gluconeogenesis
Excretes waste: ammonia, urea, bilirubin, creatinine, uric acid, meds, environmental toxins
Who is at risk for ARF
Baseline renal insufficiency: HTN, DM, post-surgical pts
"Sick" pts: old, massive trauma/burns, major surgery, CHF, sepsis, OB complications
Critical lab values to report
K: more than 6
Phos: more than 5
BUN/Creat: BUN >120
Ca: less than 7
Na: less than 120
K: less than 2.5
S/Sx to report
Cardiac: (most common cause of death) Edema, JVD, HTN, CHF, Pericardial Effusion, Pericarditis, Dysryhthmias
Pulmonary: Pulmonary edema, pulmonary HTN, Pleural Effusions
Neuro: Possible infection (malaise, fatigue, coma), Change in mental status (n/v), Metabolic Acidosis (lack of ammonia-low bicarb, lethargy, stupor)
Infection is the leading cause of death overall in ARF-meticulous aseptic technique is essential
Fluid overload: Oliguric Phase
Assess for and notify MD of edema, JVD, CHF, HTN
Perform daily weights, strict I/O's
Fluid restriction: add 600 ml (insensible loss) to urine output from day before for fluids allowed
Provide ice chips
Frequent oral care
Oliguric pts have worse outcome than nonoliguric
Fluid volume deficit: Diuretic Phase
Hypotension, dry mucous membranes, tachycardia
Replace volume hourly with last hours urine output
Fall precautions/orthostatic hypotension
Electrolyte imbalances
Oliguric: Hyperkalemia (potassium restriction, EKG); Hypocalcemia (assess for tetany)
Diuretic: Hyponatremia (sodium restriction; prevent CHF, HTN, volume expansion)
Accumulation of nitrogenous waste products
Monitor BUN/Creat
Diet high in carbs and fat
Protein restriction (controls nitrogenous waste production and limits starvation ketosis)
Preventing Infection
Strict Aseptic Technique
Avoid other infectious individuals
Skin care: prevent decubitus ulcers
Mouth care: stomatitis from ammonia
Assess/Alert MD: swelling, pain, malaise
Fever is not always present
Preventing Renal Compromise
Monitor peak and trough levels (aminoglycosides)
Renal dosing for meds
Impaired elimination of meds
Urine Creatinine Clearance (24 hour urine)
Assess/Notify MD of drug accumulation: BP meds and narcotics
Preventing Cardiac Dysrhythmias
Hyperkalemia: peaked T waves
Calcium Gluconate given to raise threshold for dysrhythmias (protects heart from high potassium)
Kayexelate is permanant removal of potassium through diarrhea, dialysis is permanant also
IV insulin drip, sodium bicarb
Increasing Cardiac Output
Positive Inotropes to improve contractility: dopamine/dobutrex
Vasopressors to increase afterload and SVR: norepinephrine IV drip
Dopamine at renal dose 1-2 mcg/kg/min to promote renal vasodilation
Nursing Care
Diet: low protein, potassium, phophate, sodium and high calories
Volume: daily weights, same scale/time
Infection control: handwashing
Medication adherence: antibiotics, antihypertensives, no NSAIDS/contrast
Lifestyle: allow for periods of rest with activity
Psych: long term recovery, anxiety, family needed for support, spiritual
R-reversible if tx early and properly
I-infection control needed
V-vital signs
E-EKG monitoring
R-report changes in mental status, critical lab values, abnormal vital signs
Clinical manifestations of Oliguric Phase
Reduced GFR
Intake greater than output
UO: less than 400ml/day
JVD, edema, HTN, pulmonary edema, effusions, Kussmauls respirations, mental status changes, EKG changes, bruising/bleeding, infection
Fixed specific gravity: 1.010
Nursing care of Oliguric Phase
I/O's, Daily weights, Abnormal labs (esp K), Fluid restriction, Nutrition (adequate protein, K, Phos, Na restriction; TPN, enteral nutrition), infection control, meticulous skin care, TCDB, mouth care for stomatitis
Lasix, Kayexelate, Calcium gluconate, iv insulin
Clinical manifestations of Diuretic Phase
UO may be 3-5 L/day
Decreased creat clearance
Increased BUN/Creat
Nursing care of Diuretic Phase
Monitor for hyponatremia, hypokalemia
Assess for dehydration
Fall precautions
IV fluids, potassium replacement
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